Health Chats
Atrial Fibrillation - Surgical and Nonsurgical Advances
Monday Apr 13, 2009, 12:00PM - 01:00PM (EST)
Cleveland Clinic
Cardiac Electrophysiology and Pacing, Cleveland, OH
Cleveland Clinic cardiovascular specialists are at the forefront of development and utilization of the newest therapies for treating atrial fibrillation (AF), the most common of all irregular heart rhythms. At the Center for Atrial Fibrillation, one of the nation's busiest AF programs, our staff provides a full array of approaches to diagnose and treat atrial fibrillation, whether medical, catheter based, or surgical. Please join us to chat with Dr. Bruce Lindsay as he takes your questions about the causes and new treatment options for atrial fibrillation.<br><br> Dr. Bruce D. Lindsay is Section Head, Cardiac Electrophysiology and Pacing at the Cleveland Clinic Sydell and Arnold Miller Family Heart & Vascular Institute. He is board-certified in Internal Medicine, Cardiology, and Clinical Cardiac Electrophysiology.He served as President of the Heart Rhythm Society 2007-2008 and chaired the Heart Rhythm Society's Annual Scientific Program in Boston in 2006, which was attended by more than 13,000 international physicians, scientists, and allied health professionals. Dr. Lindsay recently completed a term on Board of Trustees for the American College of Cardiology, and formerly chaired the College's Board of Governors. He also serves on the ABIM test writing committee for Clinical Cardiac Electrophysiology
Welcome to today's health chat with Dr. Bruce Lindsay of the Cleveland Clinic. We'll be starting in 10 minutes, but feel free to start submitting your questions now.
Welcome Dr. Lindsay. Thank you for taking the time to answer questions today. We look forward to learning more about atrial fibrillation.
Bruce D. Lindsay, MD:
Thank you for having me.
What causes atrial fibrillation?
Bruce D. Lindsay, MD:
Atrial fibrillation is caused by abnormal electrical activation of the atria.  Sometimes, this is caused by extensive damage to the atrium from underlying heart disease.  In many patients, it originates at the attachment of the pulmonary veins to the left atria.
Bruce D. Lindsay, MD:
The muscle cells at this junction send out rapid electrical discharges that trigger atrial fibrillation.  Nerve inputs to the heart, stretching of muscle fibers and other factors seem to be important in starting atrial fibrillation.
I was wondering what should be done. I have heart palpitations frequently (3 times a day at least). They are very painful. I will have a heart monitor put on Wednesday.  Is there any way I can reduce my heart rate or why it is happening?
Bruce D. Lindsay, MD:
Your doctor is approaching this correctly.  The first step is to determine the cause of your palpitations.  Depending on what your doctor finds, there are many good treatments for eliminating these symptoms.  Patients often respond to medications but when they do not, ablation procedures are effective in curing the problem.  
Bruce D. Lindsay, MD:
These procedures involve placing catheters in the heart to determine the origin of the problem and to burn out the tissue that is responsible.
Hi, on January 26th of this year I had a pulmonary ablation performed. For the first two months I felt great, now I am experiencing PVC's and PAC's (holter monitor for 48 hours showed 500 PVC and 400 PAC--I take Prevacid, Benicar, Tricor. I have had no a-fibs since the ablation--in fact I can walk and do a little running, but the PVC's and PAC's are killing me--any help would be appreciated.
Bruce D. Lindsay, MD:
PVCs and PACs are common in patients whether or not they have undergone a prior ablation procedure.  Some patients are not bothered by these extra beats while for others they are debilitating.  While they are not dangerous, they can effect your quality of life.  Treatment with medications might help to suppress these beats or a second ablation procedure might be effective.  You will need to discuss these options with your doctor.
Thank you so much for answering questions for us.  I have had an implanted defibrillator since 1994.  Prior to March of last year, my problems were always Ventricular Fibrillation, beginning in March of 2008, I began having Atrial Fibrillation. I cannot seem to distinguish between A-fib and V-fib and just wondered if there is a way for a patient like me to tell whether I'm having A-fib or V-fib?
Bruce D. Lindsay, MD:
Ventricular Fibrillation results in immediate loss of consciousness that is treated by a shock delivered from the ICD.  Atrial fibrillation may cause an increase of heart rate but it rarely causes loss of consciousness.  Sometimes patients with ICDs can experience a shock caused by atrial fibrillation if their heart rate increases beyond the detection criteria that was programmed into the ICD.  
How common is atrial fibrilation in children under 5 years old? What sort of treatment options are there?
Bruce D. Lindsay, MD:
Atrial fibrillation is very rare in children.  Sometimes it is associated with congenital heart disease.  The treatment would depend on whether the child has congenital heart disease or some other heart disorder.
How dangerous are a-fibs? Is it hereditary?
Bruce D. Lindsay, MD:
Atrial fibrillation is not a life threatening condition but it can cause severe symptoms in some patients. Others tolerate it without any difficulty.  We are beginning to understand that certain genes predispose patients to atrial fibrillation.  This is one of the current studies at the Cleveland Clinic.
Although I have an a-fib episode once or twice a year, my main problem is frequent episodes of frequent ectopics.  These cause me a lot of distress from anxiety, even though I know they are supposedly not dangerous.  (1) Can an ablation help those?  (2) I have heard that Flecainide can help them, but my cardiologist says it is too dangerous "just for ectopics."  Is there a med that can help?  I am currently on Toprol 100 mg a day, which is the max I can take without substantial shortness of breath even though I do not have asthma, and magnesium.  Thank you.
Bruce D. Lindsay, MD:
The response to your question is similar to one of the prior questions.  It might be feasible to treat your problem with either medications or an ablation.  The choice of medicines depends on balancing the risk of taking the medicines with the severity of your symptoms.  If your extra beats are debilitating you should talk to your doctor further or consider a second opinion.
I have had 3 ablations for paroxismal AF and one for Aflutter. No other comorbidities, no CAD, HTN, etc.  What a about a 4th ablation? I'm in the hospital now to start tikosin loading.  What are the side effects and efficacy of tikosin?
Bruce D. Lindsay, MD:
Patients often require more than one ablation to achieve a good long term result. However, if you have already had 3 ablations your problem may be more complex and may not be curable using catheter ablation techniques.  
Bruce D. Lindsay, MD:
Tikosyn is approved by the FDA for treatment of atrial fibrillation.  It must be used carefully but it is well tolerated by most patients and often alleviates symptoms.
Two and a half years ago--at age 60, I was diagnosed with A-Fib and put on solotol which did not stop the episodes, and in fact, they became worse during the last year.  Four weeks ago my doctor changed my medication to metropolol and rhymotol and since then I have not had any episodes.  Is it likely that I will remain episode-free or should I continue to prepare myself--mentally--for an ablation as I was doing before I switched medications?
Bruce D. Lindsay, MD:
Sometimes medications will work for years before the underlying problem becomes unresponsive to treatment.  Ablation procedures can be considered at that point but for now you are doing well and may continue to do well for a long period of time.
Hello Dr - I'm a 40 yr old male and had a single bout of lone a-fib just over a year ago.  Testing revealed no problems.  How likely am I to have another episode of a-fib?  Is there anything I can do to prevent it from happening again?  Thank you.
Bruce D. Lindsay, MD:
It is quite possible that you will not have another episode of atrial fibrillation for many years.  Patients can reduce the risk of atrial fibrillation by limiting or avoiding alcohol intake, keeping their weight under control or undergoing treatment for sleep apnea if they have that problem.  
I had a heart attack in May 2006, had 4 stents put in. After the heart attack I was found to be in atrial fibrillation. I am on Coumadin, plavix , aspirin and sotalol. My cardiologist attempted cardioversion twice, neither time worked. What other non surgical options are available? Since I have been in atrial fibrillation for almost three years am I still a candidate for ablation?
Bruce D. Lindsay, MD:
The success of ablation procedures is highest in patients with paroxysmal atrial fibrillation (intermittent) as opposed to long standing persistent atrial fibrillation like yours. You might benefit from another medication or an ablation procedure.  Good results can be achieved in patients like you but the success rate is lower and you are more likely to require a second ablation procedure to achieve a good long term result.
I'm 69 with a history of PSVT, heart failure, and now A-fib.  Tikosyn keeps me in NSR for the past 6 weeks, and I also take Coumadin.  I am considering the sinus node ablation due to long term effects of Tikosyn.  What are your thoughts on that procedure at this season of my life?
Bruce D. Lindsay, MD:
Sinus node ablation is  not used for treatment of atrial fibrillation so you may be confused about the use of terms.  Sinus node ablation has been performed for other conditions but the results are not so predictable.  Perhaps you are thinking of AV node ablation which in combination of a pacemaker is used to control the heart rate. it is not curative.  The alternative if you do not respond to medications is to undergo a pulmonary vein isolation, which is curative. Tikosyn can be taken for long periods of time without any known cumulative toxicity.  
I have read that if someone is in a-fib for 48 hours then they should go to the emergency room. What is the significance of this 48 hour mark and what happens at the ER? Thanks.
Bruce D. Lindsay, MD:
Patients are advised to go to the emergency room immediately if they have severe symptoms.  For those who have less severe symptoms, a trip to the emergency room can be delayed to see if the atrial fibrillation converts spontaneously.  If it persists for more than 48 hours, the risk of stroke increases in patients who are not appropriately anticoagulated.  This is not as great a concern for patients who are treated with warfarin.